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California's largest privately run immigrant detention facility – and a key holding site for immigrants from Southern California – has recorded lapses in care during a four-year period when at least three detainees have died, according to documents obtained by KPCC and interviews with former detainees and their families.

Through a FOIA request, KPCC obtained contracts and memos between the City of Adelanto, where the facility is located, and GEO Group Inc., the private company that runs it. The report spans the period from the center's opening in 2011 to 2015.

The documents, when combined with government inspection reports and detainee accounts, shed light on a facility where thousands of immigrants are held each year while applying for asylum or contesting deportation.

"It was scary, really scary"

The Adelanto Detention Facility has the capacity to hold nearly 2,000 adult detainees. (The facility holds both men and women, but no families or children.) They include people convicted of a federal crime awaiting deportation, those applying for asylum, or detainees with a removal order awaiting an immigration court date.

Unlike prisoners in the criminal justice system, detainees are in a civil process, which means they often face an uncertain processing timeline without a guaranteed attorney.

That uncertainty led to a tense, stressful environment for Carlos Hidalgo, 49, who spent 12 months in Adelanto during two detentions, first in 2013 and again in 2015.

"It was scary, really scary," said Hidalgo, who first came to the U.S. in the early 1980s with his parents fleeing El Salvador's civil war. He came to the attention of immigration authorities after pleading to a theft charge. He says he was trying to cash a bad check. "You hear stories, but you don't know until you live it."

Upon arriving in Adelanto, Hidalgo said he faced multiple challenges, including access to legal materials, long wait times for medical care and the psychological stress of being far away from his children and parents. He also said the food was of poor quality and left him constantly hungry.

"It's humiliating, it's degrading that you have to beg for food," said Hidalgo. "Why do they have to degrade you that way?"

When asked about these accounts, ICE said in a statement that detainees are served three hot meals a day at Adelanto. The agency also would not confirm other details of Hidalgo's case, citing privacy issues. (Hidalgo shared personal documents with KPCC, including medical records, bond release papers and grievance filings during his time at Adelanto.)

"The daily menus are developed by a registered dietician, who ensures individuals’ unique health, dietary and religious needs are met," ICE said in the statement. "Additionally, detainees may purchase food and personal products through the commissary, including soft drinks and snack items."

Problems cited from the start

A 2012 inspection visit from the Immigration and Customs Enforcement's Office of Detention Oversight found 26 deficiencies at the facility, nine of which it called "priority components." Those included food service, access to law libraries and legal materials and prevention and reporting of sexual abuse and assault. On the last issue, the office said it found "wide inconsistencies" in policies and record keeping.

"Of greatest concern were the discoveries that ADF [Adelanto Detention Facility] does not report all allegations of sexual abuse and assault to ERO [ICE's Enforcement and Removal Operations] and case files are not properly maintained," said the report.

The findings are at odds with the agreement drafted between the City of Adelanto and GEO Group. For example, according to the 2011 contract obtained by KPCC, GEO Group "shall develop and implement a comprehensive sexual abuse/assault prevention and intervention program."

When inspectors conducted another compliance visit two years later, they cited improvements, such as "full compliance" with an evaluation of use-of-force incidents, and in how staff handled 137 formal disciplinary actions with detainees. "Detainees were served with notice, hearings were conducted in a timely manner, and sanctions were within established guidelines," inspectors noted.

But in some cases, the findings of inspectors contrasted with what detainees described. For example, despite one out of three detainees complaining of poor food, inspectors found the food "well-balanced, with an adequate caloric count." Likewise, about half the detainees interviewed cited medical care complaints. But after reviewing the cases, inspectors found the care "appropriate and timely."

However, in reviewing the 2012 death of Fernando Dominguez-Valivia, a man from Guatemala, ICE faulted "several egregious errors committed by ACF medical staff." ICE's Office of Professional Responsibility said his death "could have been prevented and that the detainee received an unacceptable level of medical care while detained."

Another death in 2015 followed "lapses in care" at a different ICE facility preceding a detainee's death while at Adelanto. And a third death later in 2015 is under review.

History of a private prison operator

GEO Group is a Florida-based company that, according to its website, provides global "management and/or ownership of 104 correctional, detention and community reentry facilities encompassing approximately 87,000 beds, including idle beds in inventory and projects under development."

GEO Group is the second-largest for-profit prison company in the U.S., second to Corrections Corporation of America, but it ranks first in the number of immigrant detainees that move through its detention sites, according to government data at Syracuse University's TRAC. Last year, for example, more than 100,000 detainees were "booked out" through GEO Group facilities, according to the data. At Adelanto, 4,699 passed through the site.

The company has run into problems at other sites. The same year that Adelanto entered into the contract in 2011, a jury in Oklahoma found GEO Group liable in an inmate's wrongful death case. (At the time, GEO said it disagreed with the decision and would "vigorously defend" itself in an appeal.) A 2015 audit from the DOJ's Office of Inspector General found issues with staffing, reimbursement rates and waste at a GEO Group-run facility in Texas.

GEO Group declined KPCC's request for an interview or for responses in writing to specific questions, but the company did send a statement that the Adelanto facility is accredited by the American Correctional Association and meets all the compliance requirements.

The company also said there are "full-time, on-site contract monitors” from ICE at the Adelanto facility who are there to make sure they comply "with all mandated standards." (The full statement is posted below.)

Vow for reforms

During a tour of the Adelanto Detention Facility last month, David Marin, deputy field office director for U.S. Immigration and Customs Enforcement in Los Angeles, said that both ICE and GEO have sought to open the site to the public.

"When we contract with anyone, be it for detention services, providing copiers, whatever the case may be, we have to be transparent," said Marin.

That has led to improvements in several areas, including legal access and the grievance process for detainees, said Marin. Officials have also improved the intake system for detainees to make sure that proper health screening is taking place.

"Whenever there’s any type of medical issues, we’re always looking at what we can do to improve it, especially if there is an unfortunate incident like a death," said Marin. "What do we need to do to make sure this doesn’t happen again?"

Some of the criticism of the facility is misplaced, he said. If Adelanto were to shut down, he pointed out, detainees from Southern California could be sent further away from their communities.

"There are things that we have to do. We have to apprehend people. We have to take them into custody. That's the law. That's what Congress has asked us to do," said Marin. "So when we do it, we try to do it close to where we know they have resources, where their family is."

Statement from GEO Group:

"GEO’s facilities have contracts in place to provide needed services for U.S. Immigration and Customs Enforcement (ICE) pursuant to strict contractual requirements and national standards set by ICE as well as industry-leading standards set by independent accreditation entities such as the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC). Furthermore, ICE employs several full-time, on-site contract monitors who have a physical presence at each facility to ensure compliance with all mandated standards. All of GEO’s facilities under contract with ICE are also audited and inspected by the agency on a routine and unannounced basis."